Comparison of different methods of screening for preterm pre-eclampsia: cohort study

OBJECTIVE

To compare the predictive performance for pre-eclampsia (PE) of three different first-trimester mathematical models of screening, which combine maternal risk factors with mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF), and two risk scoring systems, based on NICE and ACOG recommendations.

METHODS

This was a prospective cohort study performed in eight fetal-medicine units in five different regions of Spain between September 2017 and December 2019. All pregnant women with singleton pregnancies and non-malformed live fetuses attending their routine ultrasound examination at 11+0 to 13+6 weeks' gestation were invited to participate in the study. Maternal characteristics and medical history were recorded and measurements of MAP, UtA-PI, serum PlGF and pregnancy associated plasma protein-A (PAPP-A) were converted into multiples of the median (MoM). Risks for term, preterm-PE (< 37 weeks' gestation) and early-PE (< 34 weeks' gestation) were calculated according to the FMF competing risks model, the Crovetto et al., logistic regression model, and Serra et al., Gaussian model. Patient classification based on NICE and ACOG guidelines was also performed. We estimated detection rates (DR) with their 95% confidence intervals (CIs) at a fixed 10% screen positive rate (SPR), as well as the area under the receiver operating characteristic curve (AUROC) for preterm-PE, early-PE, and all PE for the three mathematical models. For the scoring systems, we calculated DR and SPR. Risk calibration was also assessed.

RESULTS

The study population comprised of 10,110 singleton pregnancies, including 32 (0.3%) that developed early-PE, 72 (0.7%) that developed preterm-PE and 230 (2.3%) of any PE. At fixed 10% SPR, the FMF, Crovetto et al., and Serra et al., detected 82.7% (95% CI, 69.6 to 95.8%), 73.8% (95% CI, 58.7 to 88.9%), and 79.8% (95% CI, 66.1 to 93.5%) of early-PE; 72.7% (95% CI, 62.9 to 82.6%), 69.2% (95% CI, 58.8 to 79.6%), and 74.1% (95% CI, 64.2 to 83.9%) of preterm-PE and 55.1% (95% CI, 48.8 to 61.4%), 47.1% (95% CI, 40.6 to 53.5%), and 53.9% (95% CI, 47.4 to 60.4%) of all PE, respectively. The best correlation between predicted and observed cases was achieved by the FMF model, with an AUROC of 0.911 (95% CI, 0.879 to 0.943), a slope of 0.983 (95% CI, 0.846-1.120) and an intercept of 0.154 (95% CI, -0.091 to 0.397). The NICE criteria identified 46.7% (95% CI, 35.3 to 58.0%) of preterm-PE at 11% SPR and ACOG criteria identified 65.9% (95% CI, 55.4 to 76.4%) of preterm-PE at 33.8% SPR.

CONCLUSIONS

The best performance of screening for preterm-PE is achieved by mathematical models that combine maternal factors with MAP, UtA-PI and PlGF, as compared to risk-scoring systems like NICE or ACOG criteria. While all three algorithms show similar results in terms of overall prediction, the FMF model showed the best performance at the individual level. This article is protected by copyright. All rights reserved.

Performance of first-trimester combined screening for preterm pre-eclampsia: findings from cohort of 10 110 pregnancies in Spain

OBJECTIVE

To evaluate the diagnostic accuracy of the Fetal Medicine Foundation (FMF) competing-risks model, incorporating maternal characteristics, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and placental growth factor (PlGF) (the 'triple test'), for the prediction at 11-13 weeks' gestation of preterm pre-eclampsia (PE) in a Spanish population.

METHODS

This was a prospective cohort study performed in eight fetal medicine units in five different regions of Spain between September 2017 and December 2019. All pregnant women with a singleton pregnancy and a non-malformed live fetus attending a routine ultrasound examination at 11 + 0 to 13 + 6 weeks' gestation were invited to participate. Maternal demographic characteristics and medical history were recorded and MAP, UtA-PI, serum PlGF and pregnancy-associated plasma protein-A (PAPP-A) were measured following standardized protocols. Treatment with aspirin during pregnancy was also recorded. Raw values of biomarkers were converted into multiples of the median (MoM), and audits were performed periodically to provide regular feedback to operators and laboratories. Patient-specific risks for term and preterm PE were calculated according to the FMF competing-risks model, blinded to pregnancy outcome. The performance of screening for PE, taking into account aspirin use, was assessed by calculating the area under the receiver-operating-characteristics curve (AUC) and detection rate (DR) at a 10% fixed screen-positive rate (SPR). Risk calibration of the model was assessed.

RESULTS

The study population comprised 10 110 singleton pregnancies, including 72 (0.7%) that developed preterm PE. In the preterm PE group, compared to those without PE, median MAP MoM and UtA-PI MoM were significantly higher, and median serum PlGF MoM and PAPP-A MoM were significantly lower. In women with PE, the deviation from normal in all biomarkers was inversely related to gestational age at delivery. Screening for preterm PE by a combination of maternal characteristics and medical history with MAP, UtA-PI and PlGF had a DR, at 10% SPR, of 72.7% (95% CI, 62.9-82.6%). An alternative strategy of replacing PlGF with PAPP-A in the triple test was associated with poorer screening performance for preterm PE, giving a DR of 66.5% (95% CI, 55.8-77.2%). The calibration plot showed good agreement between predicted risk and observed incidence of preterm PE, with a slope of 0.983 (95% CI, 0.846-1.120) and an intercept of 0.154 (95% CI, -0.091 to 0.397).

CONCLUSIONS

The FMF model is effective in predicting preterm PE in the Spanish population at 11-13 weeks' gestation. This method of screening is feasible to implement in routine clinical practice, but it should be accompanied by a robust audit and monitoring system, in order to maintain high-quality screening. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical phenotypes for risk stratification in small-for-gestational-age fetuses

OBJECTIVE

To evaluate whether clinical phenotypes of small-for-gestational-age (SGA) fetuses can be identified and used for adverse perinatal outcome risk stratification to facilitate clinical decision-making.

METHODS

This was a multicenter observational cohort study conducted in two tertiary care university hospitals. SGA fetuses were classified according to maternal, fetal and placental conditions using a two-step cluster algorithm, in which fetuses with more than one condition were assigned to the cluster associated with the highest mortality risk. Delivery and perinatal outcomes were compared using chi-square test among SGA clusters, and the associations between outcomes and each cluster were evaluated by calculating odds ratios (OR), adjusted for gestational age.

RESULTS

The study included 17 631 consecutive singleton pregnancies, of which 1274 (7.2%) were defined as SGA at birth according to INTERGROWTH-21^st standards. Nine SGA clinical phenotypes were identified using a predefined conceptual framework. All delivery and perinatal outcomes analyzed were significantly different among the nine phenotypes. The whole SGA cohort had a three-times higher risk of perinatal mortality compared with non-SGA fetuses (1.4% vs 0.4%; P < 0.001). SGA clinical phenotypes exhibited three patterns of perinatal mortality risk: the highest risk was associated with congenital anomaly (8.3%; OR, 17.17 (95% CI, 2.17-136.12)) and second- or third-trimester hemorrhage (8.3%; OR, 9.94 (95% CI, 1.23-80.02)) clusters; medium risk was associated with gestational diabetes (3.8%; OR, 9.59 (95% CI, 1.27-72.57)), preterm birth (3.2%; OR, 4.65 (95% CI, 0.62-35.01)) and intrauterine growth restriction (3.1%; OR, 5.93 (95% CI, 3.21-10.95)) clusters; and the lowest risk was associated with the remaining clusters. Perinatal mortality rate did not differ between SGA fetuses without other clinical conditions (54.1% of SGA fetuses) and appropriate-for-gestational-age fetuses (0.1% vs 0.4%; OR, 0.41 (95% CI, 0.06-2.94); P = 0.27). SGA combined with other obstetric pathologies increased significantly the risk of perinatal mortality, as demonstrated by the increased odds of perinatal death in SGA cases with gestational diabetes compared to non-SGA cases with the same condition (OR, 24.40 (95% CI, 1.31-453.91)).

CONCLUSIONS

We identified nine SGA clinical phenotypes associated with different patterns of risk for adverse perinatal outcome. Our findings suggest that considering clinical characteristics in addition to ultrasound findings could improve risk stratification and decision-making for management of SGA fetuses. Future clinical trials investigating management of fetuses with SGA should take into account clinical information in addition to Doppler parameters and estimated fetal weight. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

STATIN trial: predictive performance of competing-risks model in screening for pre-eclampsia at 35-37 weeks' gestation

OBJECTIVE

To examine the predictive performance of a previously reported competing-risks model of screening for pre-eclampsia (PE) at 35-37 weeks' gestation by combinations of maternal risk factors, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1) in a validation dataset derived from the screened population of the STATIN study.

METHODS

This was a prospective third-trimester multicenter study of screening for PE in singleton pregnancies by means of a previously reported algorithm that combines maternal risk factors and biomarkers. Women in the high-risk group were invited to participate in a trial of pravastatin vs placebo, but the trial showed no evidence of an effect of pravastatin in the prevention of PE. Patient-specific risks of delivery with PE were calculated using the competing-risks model, and the performance of screening for PE by maternal risk factors alone and by various combinations of risk factors with MAP, UtA-PI, PlGF and sFlt-1 was assessed. The predictive performance of the model was examined by, first, the ability of the model to discriminate between the PE and no-PE groups using the area under the receiver-operating-characteristics curve (AUC) and the detection rate at a fixed false-positive rate of 10%, and, second, calibration by measurements of calibration slope and calibration-in-the-large.

RESULTS

The study population of 29 677 pregnancies contained 653 that developed PE. In screening for PE by a combination of maternal risk factors, MAP, PlGF and sFlt-1 (triple test), the detection rate at a 10% false-positive rate was 79% (95% CI, 76-82%) and the results were consistent with the data used for developing the algorithm. Addition of UtA-PI did not improve the prediction provided by the triple test. The AUC for the triple test was 0.923 (95% CI, 0.913-0.932), demonstrating very high discrimination between affected and unaffected pregnancies. Similarly, the calibration slope was 0.875 (95% CI, 0.831-0.919), demonstrating good agreement between the predicted risk and observed incidence of PE.

CONCLUSION

The competing-risks model provides an effective and reproducible method for third-trimester prediction of term PE. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Prediction of pre-eclampsia in twin pregnancy by maternal factors and biomarkers at 11-13 weeks' gestation: data from EVENTS trial

OBJECTIVES

First, to validate a previously developed model for screening for pre-eclampsia (PE) by maternal characteristics and medical history in twin pregnancies; second, to compare the distributions of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A) in twin pregnancies that delivered with PE to those in singleton pregnancies and to develop new models based on these results; and, third, to examine the predictive performance of these models in screening for PE with delivery at < 32 and < 37 weeks' gestation.

METHODS

Two datasets of prospective non-intervention multicenter screening studies for PE in twin pregnancies at 11 + 0 to 13 + 6 weeks' gestation were used. The first dataset was from the EVENTS (Early vaginal progesterone for the preVention of spontaneous prEterm birth iN TwinS) trial and the second was from a previously reported study that examined the distributions of biomarkers in twin pregnancies. Maternal demographic characteristics and medical history from the EVENTS-trial dataset were used to assess the validity of risks from our previously developed model. The combined data from the first and second datasets were used to compare the distributional properties of log₁₀ multiples of the median (MoM) values of UtA-PI, MAP, PlGF and PAPP-A in twin pregnancies that delivered with PE to those in singleton pregnancies and develop new models based on these results. The competing-risks model was used to estimate the individual patient-specific risks of delivery with PE at < 32 and < 37 weeks' gestation. Screening performance was measured by detection rates (DR) and areas under the receiver-operating-characteristics curve.

RESULTS

The EVENTS-trial dataset comprised 1798 pregnancies, including 168 (9.3%) that developed PE. In the validation of the prior model based on maternal characteristics and medical history, calibration plots demonstrated very good agreement between the predicted risks and the observed incidence of PE (calibration slope and intercept for PE < 32 weeks were 0.827 and 0.009, respectively, and for PE < 37 weeks they were 0.942 and -0.207, respectively). In the combined data, there were 3938 pregnancies, including 339 (8.6%) that developed PE and 253 (6.4%) that delivered with PE at < 37 weeks' gestation. In twin pregnancies that delivered with PE, MAP, UtA-PI and PlGF were, at earlier gestational ages, more discriminative than in singleton pregnancies and at later gestational ages they were less so. For PAPP-A, there was little difference between PE and unaffected pregnancies. The best performance of screening for PE was achieved by a combination of maternal factors, MAP, UtA-PI and PlGF. In screening by maternal factors alone, the DR, at a 10% false-positive rate, was 30.6% for delivery with PE at < 32 weeks' gestation and this increased to 86.4% when screening by the combined test; the respective values for PE < 37 weeks were 24.9% and 41.1%.

CONCLUSIONS

In the assessment of risk for PE in twin pregnancy, we can use the same prior model based on maternal characteristics and medical history as reported previously, but in the calculation of posterior risks it is necessary to use the new distributions of log₁₀ MoM values of UtA-PI, MAP and PlGF according to gestational age at delivery with PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

New approach for estimating risk of miscarriage after chorionic villus sampling

OBJECTIVE

To estimate the risk of miscarriage associated with chorionic villus sampling (CVS).

METHODS

This was a retrospective cohort study of women attending for routine ultrasound examination at 11 + 0 to 13 + 6 weeks' gestation at one of eight fetal-medicine units in Spain, Belgium and Bulgaria, between July 2007 and June 2018. Two populations were included: (1) all singleton pregnancies undergoing first-trimester assessment at Hospital Clínico Universitario Virgen de la Arrixaca in Murcia, Spain, that did not have CVS (non-CVS group); and (2) all singleton pregnancies that underwent CVS following first-trimester assessment at one of the eight participating centers (CVS group). We excluded pregnancies diagnosed with genetic anomalies or major fetal defects before or after birth, those that resulted in termination and those that underwent amniocentesis later in pregnancy. We used propensity score (PS) matching analysis to estimate the association between CVS and miscarriage. We compared the risk of miscarriage of the CVS and non-CVS groups after PS matching (1:1 ratio). This procedure creates two comparable groups balancing the maternal and pregnancy characteristics that are associated with CVS, in a similar way to that in which randomization operates in a randomized clinical trial.

RESULTS

The study population consisted of 22 250 pregnancies in the non-CVS group and 3613 in the CVS group. The incidence of miscarriage in the CVS group (2.1%; 77/3613) was significantly higher than that in the non-CVS group (0.9% (207/22 250); P < 0.0001). The PS algorithm matched 2122 CVS with 2122 non-CVS cases, of which 40 (1.9%) and 55 (2.6%) pregnancies in the CVS and non-CVS groups, respectively, resulted in a miscarriage (odds ratio (OR), 0.72 (95% CI, 0.48-1.10); P = 0.146). We found a significant interaction between the risk of miscarriage following CVS and the risk of aneuploidy, suggesting that the effect of CVS on the risk of miscarriage differs depending on background characteristics. Specifically, when the risk of aneuploidy is low, the risk of miscarriage after CVS increases (OR, 2.87 (95% CI, 1.13-7.30)) and when the aneuploidy risk is high, the risk of miscarriage after CVS is paradoxically reduced (OR, 0.47 (95% CI, 0.28-0.76)), presumably owing to prenatal diagnosis and termination of pregnancies with major aneuploidies that would otherwise have resulted in spontaneous miscarriage. For example, in a patient in whom the risk of aneuploidy is 1 in 1000 (0.1%), the risk of miscarriage after CVS will increase to 0.3% (0.2 percentage points higher).

CONCLUSIONS

The risk of miscarriage in women undergoing CVS is about 1% higher than that in women who do not have CVS, although this excess risk is not solely attributed to the invasive procedure but, to some extent, to the demographic and pregnancy characteristics of the patients. After accounting for these risk factors and confining the analysis to low-risk pregnancies, CVS seems to increase the risk of miscarriage by about three times above the patient's background risk. Although this is a substantial increase in relative terms, in pregnancies without risk factors for miscarriage, the risk of miscarriage after CVS remains low and similar to, or slightly higher than, that in the general population. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Screening for pre-eclampsia by maternal factors and biomarkers at 11-13 weeks' gestation

OBJECTIVE

To examine the performance of screening for early, preterm and term pre-eclampsia (PE) at 11-13 weeks' gestation by maternal factors and combinations of mean arterial pressure (MAP), uterine artery (UtA) pulsatility index (PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A).

METHODS

The data for this study were derived from three previously reported prospective non-intervention screening studies at 11 + 0 to 13 + 6 weeks' gestation in a combined total of 61 174 singleton pregnancies, including 1770 (2.9%) that developed PE. Bayes' theorem was used to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics, with various combinations of biomarker multiples of the median (MoM) values to derive patient-specific risks of delivery with PE at < 37 weeks' gestation. The performance of such screening was estimated.

RESULTS

In pregnancies that developed PE, compared to those without PE, the MoM values of UtA-PI and MAP were increased and those of PAPP-A and PlGF were decreased, and the deviation from normal was greater for early than late PE for all four biomarkers. Combined screening by maternal factors, UtA-PI, MAP and PlGF predicted 90% of early PE, 75% of preterm PE and 41% of term PE, at a screen-positive rate of 10%; inclusion of PAPP-A did not improve the performance of screening. The performance of screening depended on the racial origin of the women; on screening by a combination of maternal factors, MAP, UtA-PI and PlGF and using a risk cut-off of 1 in 100 for PE at < 37 weeks in Caucasian women, the screen-positive rate was 10% and detection rates for early, preterm and term PE were 88%, 69% and 40%, respectively. With the same method of screening and risk cut-off in women of Afro-Caribbean racial origin, the screen-positive rate was 34% and detection rates for early, preterm and term PE were 100%, 92% and 75%, respectively.

CONCLUSION

Screening by maternal factors and biomarkers at 11-13 weeks' gestation can identify a high proportion of pregnancies that develop early and preterm PE. © 2018 Crown copyright. Ultrasound in Obstetrics & Gynecology © 2018 ISUOG.

ASPRE trial: incidence of preterm pre-eclampsia in patients fulfilling ACOG and NICE criteria according to risk by FMF algorithm

OBJECTIVE

To report the incidence of preterm pre-eclampsia (PE) in women who are screen positive according to the criteria of the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), and compare the incidence with that in those who are screen positive or screen negative by The Fetal Medicine Foundation (FMF) algorithm.

METHODS

This was a secondary analysis of data from the ASPRE study. The study population consisted of women with singleton pregnancy who underwent prospective screening for preterm PE by means of the FMF algorithm, which combines maternal factors and biomarkers at 11-13 weeks' gestation. The incidence of preterm PE in women fulfilling the NICE and ACOG criteria was estimated; in these patients the incidence of preterm PE was then calculated in those who were screen negative relative to those who were screen positive by the FMF algorithm.

RESULTS

A total of 34 573 women with singleton pregnancy delivering at ≥ 24 weeks' gestation underwent prospective screening for preterm PE, of which 239 (0.7%) cases developed preterm PE. At least one of the ACOG criteria was fulfilled in 22 287 (64.5%) pregnancies and the incidence of preterm PE was 0.97% (95% CI, 0.85-1.11%); in the subgroup that was screen positive by the FMF algorithm the incidence of preterm PE was 4.80% (95% CI, 4.14-5.55%), and in those that were screen negative it was 0.25% (95% CI, 0.18-0.33%), with a relative incidence in FMF screen negative to FMF screen positive of 0.051 (95% CI, 0.037-0.071). In 1392 (4.0%) pregnancies, at least one of the NICE high-risk criteria was fulfilled, and in this group the incidence of preterm PE was 5.17% (95% CI, 4.13-6.46%); in the subgroups of screen positive and screen negative by the FMF algorithm, the incidence of preterm PE was 8.71% (95% CI, 6.93-10.89%) and 0.65% (95% CI, 0.25-1.67%), respectively, and the relative incidence was 0.075 (95% CI, 0.028-0.205). In 2360 (6.8%) pregnancies fulfilling at least two of the NICE moderate-risk criteria, the incidence of preterm PE was 1.74% (95% CI, 1.28-2.35%); in the subgroups of screen positive and screen negative by the FMF algorithm the incidence was 4.91% (95% CI, 3.54-6.79%) and 0.42% (95% CI, 0.20-0.86%), respectively, and the relative incidence was 0.085 (95% CI, 0.038-0.192).

CONCLUSION

In women who are screen positive for preterm PE by the ACOG or NICE criteria but screen negative by the FMF algorithm, the risk of preterm PE is reduced to within or below background levels. The results provide further evidence to support the personalized risk-based screening method that combines maternal factors and biomarkers. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Genitourinary syndrome of menopause. Prevalence and quality of life in Spanish postmenopausal women. The GENISSE study

OBJECTIVE

To determine the prevalence of genitourinary syndrome of menopause (GSM) and urogynecological conditions associated with menopause, and to evaluate the impact of GSM on quality of life in a cohort of Spanish postmenopausal women.

METHODS

Multicenter, cross-sectional, and observational study involving 430 women.

RESULTS

The prevalence of GSM was 70%. GSM was diagnosed in 60.2% of women with no known diagnosis of vulvovaginal atrophy or GSM. Most prevalent symptoms were vaginal dryness (93.3%) and reduced lubrication with sexual activity (90.0%). Most prevalent signs were decreased moisture (93.7%) and loss of vaginal rugae (78.4%). GSM was significantly associated with stress or mixed urinary incontinence, overactive bladder, and vaginal prolapse. Symptoms showed a low-moderate impact on quality of life, mainly in sexual functioning and self-concept and body image.

CONCLUSIONS

The GSM is very prevalent in Spanish postmenopausal women, affecting up to 70% of those consulting the gynecologist. Despite the high prevalence of symptoms and signs and its impact on the women's well-being, GSM remains underdiagnosed and undertreated. Given its relationship with urogynecological conditions, it seems necessary to provide an adequate evaluation of postmenopausal women for identifying potential co-morbidities and providing most adequate treatments. An adequate management of GSM will contribute to an improvement in the quality of life of these women.

sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain)

OBJECTIVE

A high ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) has been linked to pre-eclampsia (PE). We evaluated the sFlt-1/PlGF ratio as a predictive marker for early-onset PE in women at risk of PE.

METHODS

This prospective, Spanish, multicenter study included pregnant women with a risk factor for PE, including intrauterine growth restriction, PE, eclampsia or hemolysis, elevated liver enzymes and low platelet count syndrome in previous pregnancy, pregestational diabetes or abnormal uterine artery Doppler. The primary objective was to show that the sFlt-1/PlGF ratio at 20, 24 and 28 weeks' gestation was predictive of early-onset PE (< 34 + 0 weeks). Serum sFlt-1 and PlGF were measured at 20, 24 and 28 weeks. Multivariate logistic regression was used to develop a predictive model.

RESULTS

A total of 819 women were enrolled, of which 729 were suitable for analysis. Of these, 78 (10.7%) women developed PE (24 early onset and 54 late onset). Median sFlt-1/PlGF ratio at 20, 24 and 28 weeks was 6.3 (interquartile range (IQR), 4.1-9.3), 4.0 (IQR, 2.6-6.3) and 3.3 (IQR, 2.0-5.9), respectively, for women who did not develop PE (controls); 14.5 (IQR, 5.5-43.7), 18.4 (IQR, 8.2-57.9) and 51.9 (IQR, 11.5-145.6) for women with early-onset PE; and 6.7 (IQR, 4.6-9.9), 4.7 (IQR, 2.8-7.2) and 6.0 (IQR, 3.8-10.5) for women with late-onset PE. Compared with early-onset PE, the sFlt-1/PlGF ratio was significantly lower in controls (P < 0.001 at each timepoint) and in women with chronic hypertension (P < 0.001 at each timepoint), gestational hypertension (P < 0.001 at each timepoint) and late-onset PE (P < 0.001 at each timepoint). A prediction model for early-onset PE was developed, which included the sFlt-1/PlGF ratio plus mean arterial pressure, being parous and previous PE, with areas under the receiver-operating characteristics curves of 0.86 (95% CI, 0.77-0.95), 0.91 (95% CI, 0.85-0.97) and 0.93 (95% CI, 0.86-0.99) at 20, 24 and 28 weeks, respectively, and was superior to models using the sFlt-1/PlGF ratio alone or uterine artery mean pulsatility index.

CONCLUSIONS

The sFlt-1/PlGF ratio can improve prediction of early-onset PE for women at risk of this condition. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Pharmacokinetics and preliminary efficacy of two vaginal gel formulations of ultra-low-dose estriol in postmenopausal women

OBJECTIVES

To investigate the pharmacokinetics, safety and preliminary effectiveness of ultra-low-dose estriol vaginal gel formulations (20 μg/g (T1) and 50 μg/g (T2)) compared to Ovestinon® (estriol 500 μg/0.5 g (R)) and placebo in postmenopausal women.

METHODS

Forty-three volunteers were randomly assigned to received T1, T2, R or placebo once daily for 21 days. Absorption of estriol after single and multiple administration was analyzed. Cytological changes in the vagina, tolerability and safety were also investigated.

RESULTS

Thirty-six women were included in the pharmacokinetic analysis. Systemic absorption was lower with test formulations (AUC0-t: 171.65 ± 80.18 (T1) and 406.75 ± 199.53 (T2) pg/ml × h) than with Ovestinon® (1221.97 ± 549.06 pg/ml × h). Estriol exposure of the test formulations after multiple administration (AUCss: 36.33 ± 30.52 (T1) and 73.71 ± 46.86 (T2) pg/ml × h) was significantly lower than after single-dose administration and not significantly different between them. In contrast, the exposure after repeated administration of Ovestinon® was considerable and not statistically different from levels after single administration. All estriol formulations produced similar improvement in the vaginal maturation value, while placebo showed a small and not significant change. Overall safety and acceptability were good.

CONCLUSIONS

Estriol 20 and 50 μg/g formulations, while showing a comparable capacity for reversing vaginal atrophy, present a highly favorable safety profile, producing a very low systemic absorption of estriol and significantly lower than that of Ovestinon®.

The effects of meteorological factors on airborne fungal spore concentration in two areas differing in urbanisation level

Although fungal spores are an ever-present component of the atmosphere throughout the year, their concentration oscillates widely. This work aims to establish correlations between fungal spore concentrations in Porto and Amares and meteorological data. The seasonal distribution of fungal spores was studied continuously (2005-2007) using volumetric spore traps. To determine the effect of meteorological factors (temperature, relative humidity and rainfall) on spore concentration, the Spearman rank correlation test was used. In both locations, the most abundant fungal spores were Cladosporium, Agaricus, Agrocybe, Alternaria and Aspergillus/Penicillium, the highest concentrations being found during summer and autumn. In the present study, with the exception of Coprinus and Pleospora, spore concentrations were higher in the rural area than in the urban location. Among the selected spore types, spring-autumn spores (Coprinus, Didymella, Leptosphaeria and Pleospora) exhibited negative correlations with temperature and positive correlations both with relative humidity and rainfall level. On the contrary, late spring-early summer (Smuts) and summer spores (Alternaria, Cladosporium, Epicoccum, Ganoderma, Stemphylium and Ustilago) exhibited positive correlations with temperature and negative correlations both with relative humidity and rainfall level. Rust, a frequent spore type during summer, had a positive correlation with temperature. Aspergillus/Penicillium, showed no correlation with the meteorological factors analysed. This knowledge can be useful for agriculture, allowing more efficient and reliable application of pesticides, and for human health, by improving the diagnosis and treatment of respiratory allergic disease.

Continuing Medical Education: an international reality

We are all aware today of the growing interest in continuing medical education (CME) programmes in many European Countries and it is important to understand why and how CME could become an international reality. It is obvious that patients need a good doctor--the best possible--as far as medical knowledge, attention to the patient's quality of life and cost-control is concerned. All European health care systems have to take into consideration everything that causes patient dissatisfaction, risk management and unjustified expenses. An example is the increase of claims and complaints against doctors and the strong attention of patients to medical procedures. In other words, medicine worldwide is becoming a service industry and has to consider quality and quantity of performances as well as to pay attention to personal responsibility. The object of our work is to evaluate the CME systems present in Europe, to show the work done on CME by the CME Committee of the European Academy of Allergology and Clinical Immunology and to highlight the Consensus Report on CME approved by an international panel of CME experts.

Gastroduodenal pathophysiology of NSAIDS. Short summaries of the slides

We need to learn a lot more about the pathophysiology of NSAIDs, especially COX-2, which at present are the drugs of choice.

17beta-estradiol prevents oxidative stress and decreases blood pressure in ovariectomized rats

In this study, we tested whether estrogen deficiency is associated with oxidative stress and decreased nitric oxide (NO) production, which could be responsible for an increased blood pressure in ovariectomized rats. Hemodynamic studies were performed on conscious, chronically instrumented rats. Chronic estrogen replacement on ovariectomized rats lowered blood pressure approximately 13 mmHg, from 119 +/- 3 mmHg in ovariectomized rats to 106 +/- 3 mmHg in ovariectomized-treated rats; it was also accompanied by an increase in cardiac index and vascular conductance, achieving hemodynamic values similar to those shown by sham-operated rats. N(G)-nitro-L-arginine methyl ester administration lowered significantly less the vascular conductance (0.14 +/- 0.01 vs. 0.22 +/- 0.03 and 0.26 +/- 0.01 ml. min(-1). mmHg(-1)/100 g; P < 0.05) in ovariectomized rats than in the sham-operated and estrogen-treated ovariectomized rats, respectively. Estrogen replacement prevented the lower plasma levels of nitrites/nitrates observed in ovariectomized rats. The lower plasma total antioxidant status and reduced thiol groups and the increase in plasma lipoperoxides presented in ovariectomized animals were reestablished with the estrogen treatment. These results show that estrogen administration decreases blood pressure and increases vascular conductance in ovariectomized rats. This effect may be related to an increase in NO synthesis and/or preventing oxidative stress, then improving endothelial function.

Effect of N-acetylcysteine on vascular endothelium function in aorta from oophorectomized rats

1. Experiments were performed to examine and to compare vascular endothelial function in aortic rings from oophorectomized and from ovary-intact rats and to test the effect of thiol compound as N-acetylcysteine on endothelial function. 2. In precontracted aortic rings from oophorectomized and intact rats, vascular endothelial function was evaluated by measuring changes in isometric force in response to cumulative doses of superoxide dismutase, acetylcholine and sodium nitroprusside. 3. In studies designed to assess the tone-related release of nitric oxide from aortic rings moderately precontracted with phenylephrine, superoxide dismutase produced a lower concentration-related relaxant response in aortic rings from oophorectomized rats than from ovary intact rats. 4. Acetylcholine caused a concentration- and endothelium-dependent relaxation of less magnitude in aortic rings from oophorectomized animals compared with those from ovary-intact rats. Addition of N-omega-nitro-L-arginine methyl ester eliminated the relaxation induced by both superoxide dismutase and acetylcholine. 5. No differences between groups were noticed in the concentration-relaxation curve induced by sodium nitroprusside. 6. Preincubation with N-acetylcysteine normalized the depressed vasorelaxant response to acetylcholine in the aortic rings from oophorectomized rats, whereas the concentration-response curve for acetylcholine in aortic rings from ovary-intact rats did not alter. 7. These results suggest that the absence of ovary estrogens is associated with a vascular endothelium dysfunction that can be reverted by addition of N-acetylcysteine, a thiol-containing compound with a free radical scavenger effect.

[Diagnostic criteria of infective endocarditis: from Von Reyn to Duke. Transthoracic and transesophageal echocardiography]

The Von Reyn criteria determine only a small number of definitive diagnoses of infectious endocarditis, while it is mainly diagnosed by histopathological confirmation in surgery or autopsy. This necessitates carrying out a new diagnostic scheme with accurate sensitivity and specificity based on rigorous clinical support. This scheme is provided by the Duke University criteria, which enhance the role of conventional and transesophageal echocardiography, in the diagnosis of infectious endocarditis. Echocardiography is the only accurate procedure for a non invasive diagnosis of vegetation, the main lesion in this pathology. Often, tissue destruction causes regurgitation, which is responsible for hemodynamic impairment or allows the spread of the infectious process to perivalvular tissue and can form an abscess. These complications and many others, which are difficult to treat, require an early diagnosis of this disease. Sensitivity of transesophageal technique to detect vegetations and complications is higher than that observed in conventional echocardiography, above all in patients with prosthetic valves. If the transesophageal study is negative, the existence of an infectious endocarditis is quite unlikely. Nevertheless, we need to consider clinical features, as the specificity of this technique is moderate.

Hemodynamic effect of 17 beta-estradiol in absence of NO in ovariectomized rats: role of angiotensin II

Previous reports correlate plasma levels of estrogen with increased nitric oxide (NO) production. To investigate whether the hemodynamic effects of estrogens are mediated by NO, we compared the hemodynamic changes induced by 17 beta-estradiol (100 micrograms/kg) in the absence and presence of the NO synthesis inhibitor N omega-nitro-L-arginine methyl ester (L-NAME). All protocols were performed in ovariectomized, conscious rats. Estradiol alone resulted in no significant changes in cardiac index (CI) or mean arterial pressure (MAP). However, in the presence of L-NAME, estradiol induced a significant increase in total peripheral resistance (TPR) of 37.3 +/- 11.7% and a decrease in CI of 27 +/- 4.9%, without changes in MAP. Previous blockade of angiotensin II AT1 receptors with losartan prevented any change in CI and TPR induced by 17 beta-estradiol in the presence of L-NAME. These observations suggest that NO is necessary to offset a vasoconstrictor action of angiotensin II, which is stimulated by estradiol administration.

Fronto-striato-thalamic perfusion and clozapine response in treatment-refractory schizophrenic patients. A 99mTc-HMPAO study

Several studies with functional and structural brain-imaging techniques support the hypothesis that responders and non-responders to clozapine could show a different pattern of cerebral dysfunction. Thirty-nine neuroleptic-refractory schizophrenic patients were studied with 99Tc-labelled hexamethyl-propylene-aminoxime (HMPAO) and SPECT, while on classical neuroleptics and after 6 months of treatment with clozapine. The perfusion differences between responders and non-responders to clozapine were studied in the regions included within the dorsolateral and orbitofrontal fronto-striato-thalamic circuits, as well as the predictive value of these parameters. These values were compared to those of a normal database, and between both treatments within the two groups. On-neuroleptic perfusion in non-responders was lower in the thalamus, basal ganglia and dorsolateral prefrontal cortex. Thalamus and right prefrontal perfusion regions were selected as response predictors by a discriminant analysis. Thalamic and left basal ganglia activities while on neuroleptics were lower only in non-responders with respect to the normal subjects. Perfusion changes were only observed in the responder group in thalamus and basal ganglia. Study of regional perfusion may contribute to the prediction of clozapine response.

Locally released retinoic acid leads to facial clefts in the chick embryo but does not alter the expression of receptors for fibroblast growth factor

Systemic administration of retinoic acid (RA) affects the growth of the upper beak of chick embryos; however, the mechanism for generating a cleft upper beak is not known. In the present study, we wished to elucidate the molecular basis of the retinoid-induced lip clefting. In order to ensure that facial prominences were locally exposed to levels of retinoid known to affect gene expression, we implanted beads soaked in different concentrations of RA in the right nasal pit or in the centre of the frontonasal mass. Beads soaked in 5 mg/ml RA placed in the right nasal pit caused full clefting of the upper beak with a deviation of the midline toward the right side of the face. The asymmetry was principally due to a decrease in size or total elimination of the right lateral nasal prominence. RA-soaked beads placed in the centre of the frontonasal mass created full bilateral clefts that were more symmetrical than those produced by beads in the nasal pit. Lower concentrations of retinoic acid produced less severe facial abnormalities. Control experiments show that the implanted bead itself has no effect on growth or fusion of the facial prominences. The specific effects of retinoids on facial growth may be due to a localized decrease in responsiveness to growth factors. Gene expression patterns for two fibroblast growth factor receptors (Cek-2, Cek-3, [chicken embryo kinase]) in normal and RA-treated embryos were examined by in situ hybridization. In normal embryos, Cek-2 and Cek-3 transcripts are expressed at very high levels in the mesenchyme directly adjacent to the eye. Cek-3 is additionally expressed in the centre of the frontonasal mass. The application of beads to the right nasal pit did not change the level of expression or distribution of transcripts for Cek-2 or Cek-3. This data suggests that retinoic acid may be affecting other aspects of the FGF receptor-ligand interaction.

Environmental health and Hispanic children

There are numerous indicators that Hispanics face a disproportionate risk of exposure to environmental hazards. Ambient air pollution, worker exposure to chemicals, indoor air pollution, and drinking water quality are among the top four threats to human health and are all areas in which indicators point to elevated risk for Hispanic populations. These data, juxtaposed with data on the health status of Hispanics, tell us that the environmental health status of Hispanics and their children is poor. At the same time, significant inadequacies in the collection of data on Hispanics make it difficult to make improving Hispanic environmental health status a priority. These inadequacies include the failure to use Hispanic identifiers in data collection and failure to collect sample sizes large enough to allow for breakouts of data by Hispanic subgroup. In addressing environmental justice issues, the U. S. Environmental Protection Agency (U.S. EPA) and the Department of Health and Human Services (DHHS) should prioritize improving the quantifiability of environmental exposures and risk based on race or ethnicity. However, improving data should not be the prerequisite to significant, affirmative steps by DHHS and U.S. EPA to address environmental and environmental health problems facing Hispanic communities. In particular, a health-based approach to environmental justice should be the priority.

Improving data collection strategies

The authors examined 21 major health data systems of the U.S. Department of Health and Human Services (DHHS) and concluded that data on Hispanics are not included in several Departmental national health data collection systems, and that even when collected, data on Hispanic subpopulations are found in few of the systems. Of the 21 data systems, 6 do not collect Hispanic population data, including the Medicare statistical system. Only the National Vital Statistics System was found to collect data for all major Hispanic subpopulation groups. Seventeen of the 21 data systems do not collect sample sizes adequate for analyzing any one of the four major Hispanic subpopulation groups. To address that lack, Hispanic health leadership agendas have recommended collecting data on Hispanics in all systems, where possible, to provide samples of a size adequate for detailed analysis of Hispanic subpopulation groups, for support of researchers and a Hispanic research infrastructure, and for broad dissemination of data findings, including dissemination in useful formats to Hispanic community-based organizations.

Hispanic Health and Nutrition Examination Survey: methodological considerations

The Hispanic Health and Nutrition Examination Survey (HHANES) was the first special population survey undertaken by the National Center for Health Statistics. The HHANES was designed to assess the health and nutritional status and needs of Mexican Americans, mainland Puerto Ricans and Cuban Americans. Data were collected using five data collection techniques: direct physical examinations, diagnostic testing, anthropometry, laboratory analyses, and interviews. Unlike other surveys conducted by the National Center for Health Statistics, the HHANES was not designed as a national survey. The HHANES was a survey of three Hispanic subgroups of the population in selected areas of the United States with a survey universe that included approximately 76 percent of the 1980 Hispanic-origin population in the United States. This article discusses statistical issues that should be addressed by researchers when analyzing HHANES data. Specifically, analysts need to account for the complex sample design, nonresponse bias, potential non-coverage bias, and the regional nature of the HHANES sample.

Reaching Hispanics with messages to prevent alcohol and other drug abuse

Hispanics are often labeled a "hard-to-reach" population in the context of health communications, yet there are indicators that corporate interests increasingly are reporting successes in designing advertising and promotional campaigns targeting Hispanic markets. The authors suggest research priorities designed to promote more effective communications programming in the substance abuse field, and they identify three key target audiences: children and adolescents, women of childbearing age, and heavy-drinking men. The significance of the diversity within the Hispanic community; the opportunities to reinforce attitudes, norms, and behaviors that counter substance use; and the centrality of family are discussed as approaches to communications planning and message development.

Massive pericardial effusion produced by extracardiac malignant neoplasms

Twelve patients with extracardiac malignant neoplasms and signs of severe systemic venous hypertension were admitted during the last three years to our service. It was the initial manifestation of malignant disease in six patients. Echocardiograms revealed large pericardial effusion in the 12 patients and six patients met the clinical criteria of cardiac tamponade. Pericardiocentesis was a safe procedure to give temporary relief to their problem. Cytologic examination of the pericardial fluid disclosed malignant neoplasms in 11 cases (91.6%), enabling us to make histological diagnosis in five. The most frequent site of origin was the lung (eight cases), adenocarcinoma being the predominant histologic feature. We conclude that metastatic pericardial disease must be considered as a frequent cause when a patient is initially seen with a massive pericardial effusion and/or cardiac tamponade that worsens with prognosis.